Skip to main content
Providers

Join Our Provider Network – Dental Providers

This submission is a request for participation only and not the formal credential application.
Please allow up to 10 business days for a response.

Submitter Contact Information

* Indicates required field

Providers that utilize CAQH may enter their CAQH Provider ID in the space below. After review of the participation request submitted, UPMC Health Plan will retrieve the provider's CAQH application for credentialing. Please ensure CAQH has recently been attested, all documentation is current, and UPMC has authorization to view the application.

CRNPs, CNMs, and PAs: Please attach a copy of the collaborative agreement to the CAQH application documentation.

Submitter Contact Information

Submitter Contact Information

 
 
Provider Information – All providers fill out this section

Physician Information

 

Please be aware that you may not qualify to be contracted for all the products you have selected.

PROMISe ID and Medicare numbers are required to participate with Medicaid and Medicare Products.

If you are an Oral & Maxillofacial Surgery provider or an Ophthamologist, please fill out our Medical provider form.

Practice Information

Practice Information

Please list locations where provider regularly sees patients.


Primary Practice:
 
 

Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.

Secondary Practice:
 
 

Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.

Additional Practice:
 
 

Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.

Additional Practice:
 
 

Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.

Providers that utilize CAQH may enter their CAQH provider ID in the space below. After review of the participation request submitted, UPMC Health Plan will retrieve the provider’s CAQH application for credentialing.

CRNPs, CNMs, and PAs: Please attach a copy of the collaborative agreement to the CAQH application documentation.

Oral surgery providers will need to complete credentialing with UPMC Health Plan for Medical and SKYGEN/UPMC Health Plan Dental Advantage for routine dental products.

Please note, PROMISe ID and Medicare numbers are required to participate with Medicaid and Medicare Products

By submitting this request for participation, I hereby attest that all of the information I am about to submit is true and accurate to the best of my knowledge. I understand that any information provided pursuant to this attestation that is subsequently found to be untrue and/or incorrect could result in my termination from UPMC Health Plan should I be approved.